Mortality in ASIA Impairment Scale grade A to D Patients With Odontoid Fracture and Magnetic Resonance Imaging Evidence of Spinal Cord Injury.

Odontoid fractures are common, often presenting in the elderly after a fall and infrequently associated with traumatic spinal cord injury (tSCI). The goal of this study was to analyze predictors of mortality and neurological outcome when odontoid fractures were associated with signal change on magnetic resonance imaging (MRI) at admission. Over an 18-year period (2001-2019), 33 patients with odontoid fractures and documented tSCI on MRI were identified. Mean age was 65.3 years (standard deviation [SD] = 17.2), and 21 patients were male. The mechanism of injury was falls in 25 patients, motor vehicle accidents in 5, and other causes in 3. Mean Injury Severity Score (ISS) was 40.5 (SD = 30.2), Glasgow Coma Scale (GCS) score was 13 (SD = 3.4), and American Spinal Injury Association (ASIA) motor score (AMS) was 51.6 (SD = 42.7). ASIA Impairment Scale (AIS) grade was A, B, C, and D in 9, 2, 3, and 19 patients, respectively. Mean intramedullary lesion length was 32.3 mm (SD = 18.6). The odontoid peg was displaced ventral or dorsal in 15 patients. Twenty patients had surgical intervention: anterior odontoid screw fixation in 7 and posterior spinal fusion in 13. Eleven (33.3%) patients died in this series: withdrawal of medical care in 5; anoxic brain injury in 4; and failure of critical care management in 2. Univariate logistic regression indicated that GCS score (p < 0.014), AMS (p < 0.002), AIS grade (p < 0.002), and ISS (p < 0.009) were risk factors for mortality. Multi-variate regression analysis indicated that only AMS (p < 0.002) had a significant relationship with mortality when odontoid fracture was associated with tSCI (odds ratio, 0.963; 95% confidence interval, 0.941-0.986).

Rates and Predictors of Surgery for Lumbar Disc Herniation Between the Military and Civilian Health Care Systems.

STUDY DESIGN: Retrospective review (level of evidence III). OBJECTIVE: Surgical care patterns for lumbar disc herniation (LDH), a common musculoskeletal condition of high relevance to the Military Health System (MHS), have not been described or compared across the direct care and purchased care MHS components. This study aimed to describe surgery rates in MHS beneficiaries who were diagnosed with LDH in direct care versus purchased care and to evaluate characteristics associated with the location of surgery. Differences in care patterns for LDH may suggest unexpected variation within the centrally managed MHS. METHODS: We described 1-year rates of surgery among beneficiaries who were diagnosed with LDH in direct care versus purchased care. Among beneficiaries who were diagnosed in direct care and had surgery, multivariable logistic regression models were used to identify characteristics associated with surgery location. RESULTS: We identified 726,638 MHS beneficiaries who were diagnosed with LDH in direct care or purchased care during the 9-year study period. One-year surgery rates were 10.1% in beneficiaries who were diagnosed in direct care versus 11.3% in beneficiaries who were diagnosed in purchased care. Among the 7467 patients who were diagnosed in direct care and had surgery within 1 year, characteristics associated with lower probability of surgery in purchased care versus direct care included diagnosing facility type (hospital with a neurosurgery or spine specialty versus clinic (odds ratio [OR], 0.12 (95% CI, 0.10-0.15)), Navy versus Army (OR, 0.24 (95% CI, 0.21-0.28)), and diagnosing facility specialty (Medical Expense and Performance Reporting System) (surgical care (OR, 0.33 (95% CI, 0.27-0.40)) and orthopedic care (OR, 0.39 (95% CI, 0.33-0.46)) versus primary care. The presence of comorbidities was associated with higher probability of surgery in purchased care versus direct care (OR, 1.20 (95% CI, 1.06-1.36)). CONCLUSIONS: The 1-year rate of surgery for LDH was modestly higher in beneficiaries who were diagnosed in purchased care versus direct care. Among patients who were diagnosed in direct care, several patient-level and facility-level characteristics were associated with receiving surgery in purchased care, suggesting potentially unexpected variation in care utilization across components of the MHS.

Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care.

Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.

Creating a Culture of Collaboration: A Brief History of Academic Neurosurgery in Washington, DC.

Clinical neurosurgery has been practiced in the US capital for just over 100 years. As former residents and fellows of Drs. Harvey Cushing and Walter Dandy moved to the region, hospitals at Georgetown and George Washington Universities became early adopters of this new surgical discipline. Later academic neurosurgery programs were established at the National Institutes of Health, Walter Reed Medical Center, and Children's National Medical Center. Neurosurgical pioneers at these institutions developed new technologies and diagnostic procedures which continue to inform our current practice. In addition, continued collaboration between the multiple training sites in Washington, DC has uniquely enriched our residents' training experience.

Slowly cycling Rho kinase-dependent actomyosin cross-bridge "slippage" explains intrinsic high compliance of detrusor smooth muscle.

Biological soft tissues are viscoelastic because they display time-independent pseudoelasticity and time-dependent viscosity. However, there is evidence that the bladder may also display plasticity, defined as an increase in strain that is unrecoverable unless work is done by the muscle. In the present study, an electronic lever was used to induce controlled changes in stress and strain to determine whether rabbit detrusor smooth muscle (rDSM) is best described as viscoelastic or viscoelastic plastic. Using sequential ramp loading and unloading cycles, stress-strain and stiffness-stress analyses revealed that rDSM displayed reversible viscoelasticity, and that the viscous component was responsible for establishing a high stiffness at low stresses that increased only modestly with increasing stress compared with the large increase produced when the viscosity was absent and only pseudoelasticity governed tissue behavior. The study also revealed that rDSM underwent softening correlating with plastic deformation and creep that was reversed slowly when tissues were incubated in a Ca2+-containing solution. Together, the data support a model of DSM as a viscoelastic-plastic material, with the plasticity resulting from motor protein activation. This model explains the mechanism of intrinsic bladder compliance as "slipping" cross bridges, predicts that wall tension is dependent not only on vesicle pressure and radius but also on actomyosin cross-bridge activity, and identifies a novel molecular target for compliance regulation, both physiologically and therapeutically.

Performance of Cervical Arthroplasty at a Pseudarthrosed Level of a MultiLevel Anterior Cervical Discectomy and Fusion: Case Report.

OBJECTIVE: To present a conversion from an anterior cervical discectomy and fusion (ACDF) to cervical arthroplasty in a 40-year-old, active duty member and perform a review of the literature. METHODS: A helicopter pilot in the U.S. Army underwent a three-level ACDF in 2010 at a nonmilitary institution for symptoms of bilateral upper-extremity radiculopathy. His symptoms resolved; however, per regulations, he was grounded. The patient recently presented at our clinic for evaluation of axial neck and intrascapular pain with radiographic evaluation revealing pseudarthrosis at C6-7 with segmental motion without facet joint degeneration. Surgery was performed to remove the existing allograft and replace it with an artificial disc, thus restoring a motion segment. RESULTS: Postoperative imaging reveals appropriate placement of the artificial disc and range of motion at C6-7 with the patient reporting improvement in neck pain. He has since been granted a waiver to return to active flight status. CONCLUSIONS: Revision of ACDF to arthroplasty is an exceedingly rare procedure with only two cases reported in the literature. Here, the authors demonstrate use of the procedure for a military career-specific application. When facet joint degeneration or ankylosis is absent, restoration of motion can successfully, and safely, be achieved.

Early decompressive craniectomy for severe penetrating and closed head injury during wartime.

OBJECT: Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater. METHODS: The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1-2 years. RESULTS: Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 +/- 4.2 vs 10.8 +/- 4.0, p < 0.05) and higher ISSs (32.5 +/- 9.4 vs 26.8 +/- 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1-2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 +/- 0.9 vs 3.7 +/- 0.9, 3.5 +/- 1.2 vs 4.0 +/- 1.0, and 3.7 +/- 1.2 vs 4.4 +/- 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3. CONCLUSIONS: This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.

Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system.

BACKGROUND: During the past 5 years of Operation Iraqi Freedom (OIF), a significant majority of the severe closed and penetrating head trauma has presented for definitive care at the National Naval Medical Center (NNMC) in Bethesda, MD, and at the Walter Reed Army Medical Center (WRAMC) in Washington, DC. The purpose of this article is to review our experience with this population of patients. MATERIALS: A retrospective review of all inpatient admissions from OIF was performed during a 5-year period (April 2003 to April 2008). Criteria for inclusion in this study included either a closed or penetrating head trauma suffered during combat operations in Iraq who subsequently received a neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all patients for whom primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow coma scale (GCS) and injury severity score at admission, and Glasgow outcome scale (GOS) at discharge, 6 months, and 1 to 2 years. RESULTS: Five hundred thirteen consultations were performed by the neurosurgery service on the aforementioned population. Four hundred eight patients met the inclusion criteria for this study (401:7, male: female; 228 penetrating brain injury, 139 closed head injury, 41 not specified). Explosive blast injury (229 patients; 56%) constituted the predominant mechanism of injury. The rates of pulmonary embolism (7%), cerebrospinal fluid leak (8.6%), meningitis (9.1%), spinal cord or column injury (9.8%), and cerebrovascular injury (27%) were characterized. Cerebrospinal fluid leak, vasospasm, penetrating head injury, and lower presenting GCS were statistically associated with longer intensive care unit stays and higher presenting injury severity scores (p < 0.05). While presenting GCS 3-5 correlated with worsened short-term and long-term GOS scores (p < 0.001), almost half of these patients achieved GOS >or=3 at 1- to 2-year follow-up. Total mortality after reaching NNMC/WRAMC was 4.4%. CONCLUSIONS: OIF has resulted in the highest concentration of severe closed and penetrating head trauma to return to NNMC and WRAMC since the Vietnam Conflict. Management scenarios were complex, incorporating principles designed to maximize outcomes in all body systems. Meaningful survival can potentially be achieved in a subset of patients with presenting GCS

Superior semicircular canal dehiscence: a new indication for middle fossa craniotomy. Case report.

Superior semicircular canal dehiscence is a recently described condition resulting in pressure-induced vertigo in affected patients. The diagnosis is established with the appearance of characteristic electronystagmographic and neuroimaging findings. This condition is amenable to surgical treatment by resurfacing of the dehiscence in the defect in the middle cranial fossa floor with preservation of superior semicircular canal function. The authors report on the treatment of a 35-year-old man with superior semicircular canal dehiscence by a joint neurosurgical and otolaryngological team.